14 - Pharyngeal and esophageal reconstruction

Abstract

While early-stage cancers in the hypopharynx and larynx are usually treated with radiotherapy, recurrent and advanced-stage cancers in the hypopharynx and larynx require surgical resection. Because of prior radiotherapy, primary closure of the hypopharynx after a salvage total laryngectomy often results in pharyngocutaneous fistulas. Traditionally, free jejunal flaps have been used to reconstruct circumferential pharyngoesophageal defects to re-establish alimentary tract continuity whereas the radial forearm flap has been frequently used to reconstruct non-circumferential defects. In recent years, however, the anterolateral thigh (ALT) flap has become the flap of choice for pharyngoesophageal reconstruction, offering superior functional outcomes, quicker recovery, and fewer donor-site morbidities. One of the most important aspects of pharyngoesophageal reconstruction following a total laryngectomy is to restore speech and swallowing functions. Tracheoesophageal puncture is currently the state of art speech reproduction method. Good speech reproduction requires the reconstructed esophagus to be able to vibrate without mucus production. For this reason, the ALT flap produces excellent TE speech. Furthermore, more than 90% of patients can resume an oral diet following pharyngoesophageal reconstruction with an ALT flap. A two-skin island ALT flap is also an excellent approach to reconstruct a “frozen neck”.